The Decision Makers

1 September 1979

Practical decisions about family size, and therefore the rate of population growth, are taken not by international organisations but by people everywhere. What do the real decision takers have to say? Here, the *NEW INTERNATIONALIST* presents three contrasting reports on family planning from the villages of India, Tanzania and Bangladesh.

India

SUNIL MEHRA talks about children to Veeradhran, father of four, in the village of Ladanenthal, in Tamil Nadu, India. "It was difficult," reports Mehra, "to find anyone willing to talk about family planning at all - some said they wouldn't talk to us at all if we mentioned family planning."

The sky has been cloudy for many days, but parched fields still wait for the rain. The village is deserted. A few young girls, seven or eight years old, carry their younger brothers and sisters around their waists. Occasionally a cart passes through the village and the children swing on the back of it, enjoying themselves. These children are survivors - so far.

Ladanenthal is a village in Remnad district of Tamil Nadu. Every second year threatens the district with drought. In a village like Ladanenthal about six children are born every month. Only two or three of them survive the wrath of the gods for the first few years of their lives.

Veeradhran is one of the few men who are in the village at this time of the day. He sits quiet and resigned in his small square but which he has rented for three rupees (about 40 cents) a month. Veeradhran has now had T.B. for two years. The disease means that he is incapable of work. "I have resigned myself to being a mother to my children. It is a change of circumstances that only the gods could have created." A neighbour tells me that Veeradhran's wife also coughs a lot. But women seem to have the endurance of mountains. She continues to work earning what a woman can, working in the fields.

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Veeradhran has four children, all girls. "If I didn't have these girls" he says "I wonder what would have happened to us by now." His two elder daughters are in his native village, Soraiyur. The eldest daughter now earns ten rupees (about 1.30) a month working for a landlord. She is only ten years of age. "Soon she will be earning twenty rupees (about $2.60) a month," Veeradhran says, "they are the saviours that the gods have sent to look after us."

His second daughter is now eight years old. She is too young to earn anything yet, but she is also staying with the landlord in his native village. "By next year she will be earning also."

Veeradhran's two younger daughters aged five years and two years, lie beside him. "They will grow up and help the family. When I think now, I wish I had even more children to help the family out of distress. Out of my seven children only these four girls have survived; 1 wonder how many of them will survive to become women."

Veeradhran strokes his youngest daughter's head as she turns in her sleep. "It all started two years ago. A local doctor told me I had T.B. All the elders in the village told me that there was only one place where I could be cured and that was Dr. Ramachandran's private clinic. I saved two hundred rupees and one day I tied them in a knot around my waist and set off for Pupukottai for T.B. treatment. The doctor did X-rays, blood test and sputum test and many others. In one week my two hundred rupees were gone and I had to come back to the village. The doctor said that 1 needed treatment with another 92 injections. I told the doctor that 1 could not afford them in this life. In those days I used to earn eight rupees a day by working as hard as I could from 5 a.m. to 6 p.m. As the days passed I became weaker and I could only earn a woman's salary of two rupees. It was a disgrace. Now there have been no rains, no crops and no work. Our lives suffer with the crops. With every drought - every living thing suffers."

A week ago Veeradhran left with his wife and two daughters and came to Ladanenthal, leaving his two elder daughters with the landlord. He sold his cart for twenty-two rupees to pay for the bus fares. Ladanenthal is the village where his father-in-law lives. "I am the housewife while my wife and her parents work in the fields," Veeradhran says, "I am more helpless than my father-in-law who is over 55 years of age when I am only 35."

It is now 2.30 in the afternoon. Rakki, Veeradhran's mother-in-law, returns from the fields. She picks up the youngest daughter who is crying with hunger. She clutches her in her arms. Selvi the youngest daughter is very undernourished. Rakki wants her daughter to have a son. She says, "Now we can only earn ten rupees a day between us. If we have sons, we can earn much more. The male children always look after the girls when they grow up".

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Rakki does not want her daughter to have the family planning operation. It is the only method she knows. "After the family planning operation, if the children die, then what can my daughter do?" Both Rakki and her daughter want more children. They are not sure if the two young ones will survive. It is most likely they already suffer from tuberculosis.

Veeradhran does not know that the Primary Health Centre can also cure T.B. "That's what they say, but you ask the people in the village who have been to the hospital also. They all say that no one cares. Even if the Primary Health Centre
can cure me, they have never told me. (The Primary Health Centre, covering a population of 100,000 has been treating only eighteen cases of T.B. A new health project started in a few villages in the same area has found over one hundred cases in its few months of work.)

Veeradhran explains that children are not a burden on the family in any way but a great help. He says that by the age of six or seven, if they survive, they begin to play a vital role in the family. At that age they start looking after the younger child. Soon they learn to do all the domestic chores like sweeping and washing. By the time they are ten they become the herders and shepherds of the village and collect fuel and by the time they are twelve they are working with their parents in the fields earning half a salary. In days of harvest they earn even more - "The division of land among our children does not worry us because we don't have any."

"They dont understand us."

Rakki reacts strongly. She cannot keep quiet - "It is alright for the family planning workers to want less children. They are well to do. They have a job with the government. They are paid a good salary. Their children do not die like ours. Many of them are unmarried and do not understand. A cooking pot on the fire and our children are all we have."

Veeradhran in his soft voice says, "The family plannmg workers do not understand our point of view. After all the hard work my family puts together we can only save one rupee per day, after we have bought our food. This one rupee has to be saved for clothing, for illness, and for other needs of the family. Can we afford to give our children anything better with this amount? Can we promise our children better education, medical care or other benefits that they talk about?

It does not matter whether we have two children or four, we can only provide the same. They don't understand that I have had seven children for four to survive. And I do not know how long they will survive. If I did not have the elder children life would be more difficult for us. What happens when my wife becomes older? Who will look after her? The family planning workers are not going to help her. Our children by the age of seven are important members of the family. If we do not have elder children the mother has to stay at home to look after the young ones and this reduces the family income. By the time they are twelve years old they are earning one-third of the family income, which is enough to feed the young ones. Sometimes when we are in circumstances which are the gods' creation, we may have to starve or do with less food. That is not the children's fault. If there are no rains it's not their fault. If they die because of illness, it is not their fault."

Veeradhran has since been visited by a doctor, and a trained village woman is giving him the necessary treatment Jor T. B. Veerad bran and his wife and children are also now in a village health­worker project.

*Sunil Mehra*, a regular contributor to the New Internationalist, was with the Voluntary Health Association of India and is now working for Appropriate Health Resources and Technologies Action Group.

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Tanzania

MAGGIE BLACK hitches a lift with a Tanzanian Mother and Child Healthcare unit operating from a LandRover based on the town of Mwanza, by Lake Victoria. She describes a day in the life of one family planning promoter, Mama Effie.

The floor of the little church has been brushed clean by the local schoolboys with rough, home-made brooms. In yet another of its incarnations, the church has become for today the Mother and Child Healthcare Clinic (MCHC. The MCHC Land Rover with its staff and its medicines has arrived from Bugando Hill Hospital in Mwanza on the shores of Lake Victoria. Already, undeterred by the drizzling rain, some mothers are queuing up outside.

The school benches have been rearranged inside the church for the various MCH `stations' through which the mothers circulate with their babies and children: weight-for-age measuring, family planning, innoculations, ante-natal care, sick children, nutrition teaching. Sterilising equipment is bubbling in the nave, while up by the altar a series of chakula bora (healthy food) posters are pinned up on the wall. Mama Effie, the family planning promoter, has unpacked her wooden box a veritable Christmas hamper of contraceptive goodies.

Many medical people, Tanzanian and expatriate, in this part of Africa are highly sceptical about the acceptability of modern family planning among women, particularly in the rural areas.

However Mama Effie and others like her have no time for such pessimism. Once the mothers have had their children weighed on the scales hung up over the Church doorway and their weight progress marked on the green `road to health' card each one carries, all those women who have borne eight children are referred automatically to Mama Effie. She waits, chatting, until she has a group of seven or so. And then the performance starts. And when Mama Effie gets into her stride, it certainly is a performance.

She holds up the packet of pills and counts her way through the month, explaining as she goes. She demonstrates the loop, how it is inserted, and how it stays in place. She has condoms and foam pessaries in her wooden box too, but it's the inter-uterine device and the pill that she concentrates on. The women giggle embarrassedly at first, but soon they start examining these curious examples of anti-pregnancy dawa (medicine).

The clinic is one of several that the MCH team from Mwanza visits on a regular basis. There is now a whole network of MCH clinics, either permanently housed and equipped, or mobile clinics served by the project Land Rover like this one, throughout the Mwanza Region. No mother is now further than ten miles away from childcare services. The project is fully integrated with the local government-provided health care services, but funding has come from various international voluntary agencies, who have paid for salaries and the vehicle running costs and all the small but essential items of equipment that such an ambitious scheme entails. Tradition must be overcome.

As far as family planning is concerned, the experience of the Mwanza project has lessons not only for rural Tanzania and other parts of Africa, but for the rest of the Third World and for Western opinion about the attitudes of Third World women towards having children as well. In the first place, as Mama Effie and the other Tanzanian staff emphasise, it is pointless to expect that people whose whole way of life leads them to want, to need and to expect to have large families are going to discard those views at the first glimpse of a packet of contraceptive pills. Rural people anywhere in the world are among the most anxious to hold fast to tradition and the least willing to experiment with risky new ideas. Limiting the number of children in the family comes into such a category.

No number of Mama Effies is going to transform family size from an average of eight to an average of three overnight, nor even in a generation, whether in Africa, India or Latin America. Mama Effie herself insists that she would never recommend a woman to have less than six children: "We are a young country, We need more children and young people to build our nation and make it strong. But more than six are difficult to feed, and where will people find the money for school uniforms?" Those are crucial questions as far as her `clients' are concerned. Until the standard of living rises considerably for these women and their families, children are seen not as
burdens but as valuable contributors in every way to the family fortunes.

At the village near Mwanza, the clinic is over for the day. The women, their brightly-patterned woollen headscarfs tied round their heads, set off for home. The schoolboys reappear with their brooms, and set back the benches for tomorrow's classes. The MCHC equipment is packed up and put in the Land Rover with the smoothness of an operation repeated regularly day in, day out. Today eight more women have been persuaded of the benefits of the pill. Not many, perhaps, in a clinic catering for 100 mums. But tomorrow there will be somewhere else to visit.

In this report from Bangladesh,
by Betsy Hartmann and Jim Boyce, the villagers of Katni say what they think about family size and what is needed from the family planning workers.

Parents in Katni are not accustomed to thinking about how many children they want. Procreation has always been something beyond their control. Allah gives children. He makes the decision. Only recently has the concept of birth control been introduced to the villagers. A wandering pot seller once told of a strange pill which prevents pregnancy. A religious leader said that taking the pill was a sin. The villagers of Katni were confused but curious.

The women of Katni whispered among themselves about it. One day they finally had a chance to see the pills. A woman passed through the village marketing them. She had bought them in town and was selling them to village women at twenty times the store price. She gave no instructions on how to use the pills properly. She only claimed that they had miraculous powers. A few daring women bought them without their husbands' knowledge. The pill did not work. It was a waste of money.

Most of the older women of Katni were tired of having children. They felt they had enough children to help with the chores and to care for them in their old age. They complained about their strength being drained away. "Look at my hair and teeth," Aktar Ali's wife said. "My hair is getting thinner each year and my teeth are falling out. My body is weak. If 1 have another child it will ruin me."

Women who scarcely had enough to eat themselves did not want any more children. "I have four children," said one. "Why do I need more? Each day I think, `What will I feed them?' I have no peace." Mofis' wife has had eleven children. She is only in her early thirties. "They say Allah gives children and taking pills is a sin," she says. "Even if it's true, I want to try them."

The older men of the village were more conservative about birth control. Many of them refused to believe it was humanly possible. They recognised the problems of over-population: pressure on the land, hungry children, the drain on resources, but their perceptions of it were often colored with fatalism.

But to the young men of the village, birth control made economic sense. Young men from large families realised that they would inherit only a small piece of land when their fathers died. They did not want this to happen to their children. The young men did not feel shy about discussing birth control. Talep was the most articulate. "Everyone wants me to get married now," he complained. "I don't want to. I'm poor. I want to get married later when I have some money. My wife can have one child, then she will use birth control. I don't want lots of children all at once."

Day after day we were bombarded with pleas for birth control, usually from women. Within a few weeks of our arrival in Katni we succumbed to the pressure. We decided to visit the government family planning office in Lalganj town. We spoke with the head officer, a young man dressed in a fine suit. In very polished Bengali, he talked to us about his many friends who had gone abroad. He gave us tea and promised that some extension workers would visit Katni in a few days.

Three days later in the hot noon sun a blue government jeep sputtered down the village path. Inside were two young women who instructed the village children to call their mothers to a meeting.

About fifteen women came. The visitors were handed bamboo fans and were seated do wooden chairs. The village women inspected the newcomers. Their fine clothes and educated accents were strange. "Are you from a foreign country?" they asked. The town women laughed.

The meeting was brief. The family planning workers spoke about the concept of birth control but did not encourage the women to ask questions.

They promised they would return in a few days with IUD's and pills for any women who wanted them. After drinking tea, they drove off. There was no meeting of village men.

A week passed, then two, then three. "When will they come back?" women asked.

Finally, six weeks later, two women extension workers arrrived in a rickshaw. The younger one was dressed in a blue and white silk sari which rustled while she walked. She also wore a thick gold
bangle on her wrist and a jewelled ring on her finger. With her was an older, obese women, the wife of a wealthy merchant.

The extension workers were escorted into a nearby bari (house) where a crowd of women quickly gathered. The woman in the silk sari surveyed the room. She looked at the village women surrounding her. She saw their torn cotton saris, their bare feet, their work-worn hands.

"Why don't you wear blouses?" she asked. "Don't you know it's immodest to show your breasts?"

The village women were too embarassed to answer this question. Most of them could not afford to wear blouses. They saved the ones they had for cold weather and special occasions. Besides, it was better not to wear a blouse when they nursed their children and worked all day in the heat.

"Can you give us pills?" Aktar Ali's wife asked.

This brought the discussion around to birth control. The family planning workers showed the women pills and told them how to use them. They also spoke about the IUD and sterilization. They neglected to tell the women about the possible side-effects of any of these methods or how they actually worked inside the body. The village women were confused, but they took the pills that were distributed. Ten women eventually started using them. Unable to read, they found it difficult to follow the arrow indicating which pill should be taken on which day. Some women had adverse reactions, feeling nausea and headache. However, most persisted and took the pills regularly. They worried about a lack of supply. They didn't expect the family planning workers to return, and felt shy about asking their husbands to buy pills in town.

This more than anything else is the real problem for the villagers of Katni. The women need an assured supply of pills. They need someone to visit them regularly, to supervise their taking of the pill, to answer their questions and to watch for side-effects.

This article is an excerpt from the authors book: Needless hunger, Voices from a Bangladesh Village. It is available for £3.00 from IFDP, 2588 Mission Street, San Francisco, CA 94110, USA.

This article is from
the September 1979 issue
of New Internationalist.
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